Professional Indemnity Insurance by Liability Brokers

IT Insurance Renewal Form...

Please fill out the following form. Once you have completed the form, click the Submit button to send your information.
Your insurance renewal will be handled promptly.

NOTE: Make sure you put in your correct email address as a copy of this submission will be emailed to that address.

Client Code:	(refer email)
Insured Name:
Email Address:
Website Address:	if applicable
No.of employees:

State gross revenue/fees for last year and an estimate for the next year:

Revenue 2010-2011 Estimated 2011-2012

Australia

USA or Canada

Elsewhere

If you conduct any part of your business in overseas countries, provide full details below:

Do you envisage any substantial changes in your activities (as
disclosed in your previous Proposal lodged with us), or are there
any major new operations contemplated during the next year? Yes No

If “Yes”, please provide details below in respect to each matter:

Are any of the Partners, Principals or Directors aware of any
claim or circumstance that might give rise to a claim against
the business or any prior business of any of their present or
former Partners, Principals or Directors? Yes No
If “Yes”, please provide details below in respect to each matter

Has any contract or project experienced cost overruns, delays
in implementation, failure of system(s) and/or product(s) to meet
full functionality during the past 12 months? Yes No
If “Yes”, please provide full details below.

Have any clients refused payment or requested a refund of monies
paid during the past 12 months? Yes No

If “Yes”, please provide full details below.

Please state the percentage of Your activities (based on income) applicable to each State

ACT NSW NT QLD SA TAS VIC WA O/Seas Total

% % % % % % % % % %

Are You involved in any of the following activites?

Adult entertainment	Yes No
Aviation, radar, aircraft, watercraft	Yes No
Agricultural applications	Yes No
Artificial intelligence application or system	Yes No
Parts of autos or other transportation equipment/controls	Yes No
Financial Transaction Software (funds trading, equity trading)	Yes No
Fire, security or emergency processes/applications (eg.CCTV)	Yes No
Gaming systems	Yes No
Industrial control systems/SCADA/robotics	Yes No
Medical/surgical software/hardware (not management systems)	Yes No
Military defence (weapons procurement, guidance systems etc.)	Yes No
Mining applications	Yes No
Pollution control device systems	Yes No
Resource processes (oil, gas, power, nuclear, waste disposal etc.)	Yes No
Telecommunications carriers	Yes No
Transport industry	Yes No
Utilities – water & power generation/distribution software	Yes No

If “Yes” to any above, please provide full details below.

Notes:
If there are any further comments, please detail here:

Declaration By submitting this Declaration, the Applicant/s acknowledge:

they are authorised by each of the other Applicants to make this Declaration,
the contents of the Declaration are true and complete,
they are under a continuing obligation to immediately inform QBE of any change in the particulars or statements contained in this Declaration or in the accompanying documents up until the contract is entered into,
they authorise QBE Insurance (Australia) Limited to give or obtain from other insurers or insurance reference bureaus or credit reporting agencies, any information about this insurance or any other insurance held by the Applicant/s.

Name of person making this declaration: Date: